Provider Demographics
NPI:1295902880
Name:PAYNE, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HOWARD ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3137
Mailing Address - Country:US
Mailing Address - Phone:723-318-7240
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician